doctorformen

ENLARGED PROSTATE AND PROSTATE INFECTION

Q: I am 51 years old and over the past four or five years I have had recurring bladder and prostate infections, a slow stream (which stops and restarts), low volume of discharge (approximately 4 ounces), and frequent urination throughout the night. My latest infection was recently when I had both a bladder and a prostate infection at the same time. My PSA level rose to 9.7 but after three months on the antibiotic, Floxin, it is now 2.7. I have been diagnosed with a slightly enlarged prostate, which my urologist is treating with 5 mg of Hytrin, which he wants me to continue taking for the rest of my life.
When the urge to urinate hits me, it usually always is urgent, but I seldom urinate over 4 ounces at one time. Sometimes I get a severe pain behind my scrotum when I arise from a chair after one of those urgent calls. I have asked my urologist why I keep getting these infections and also, could the pains be related to/or be the cause of the infections. I have also asked him about my low volume of urine and he tells me that 4 ounces is a normal flow. I once urinated in his office for a test and only urinated slightly less than 4 ounces. After I finished, the urologist inserted a catheter and drained off an additional 4 ounces. He also told me this was normal. I have asked him about problems I have experienced while on the Floxin and Hytrin and he has assured me that they are not related to the medicine. I have had trouble with dizziness, sleepiness, extreme fatigue, loss of sexual desire, depression, aching arms and legs, and dry mouth. The sleepiness got much better however, after I finished taking the Floxin.

My urologist has poor bedside manners and doesn't like to answer questions. I hope you can help me. My questions are as follows: What causes bladder and prostate infections? What is the normal volume of urine excreted by a man? What is the pain behind my scrotum and could it be related to my problems? What are the short and long-term affects associated with the use of Hytrin? What is the normal amount of urine retained in the bladder after urination?

I hope that you can help me, I would appreciate any response.

A - As a young man of 51, these significant complaints are not normal. It is unfortunate that your urologist is not to your liking and you should seek a second opinion with another urologist - after all, you are the medical consumer and should be satisfied. Bladder and prostate infections are caused by bacteria that usually enter the system from the outside via the urethra. Bladder infection may be caused by an enlarged prostate whereby all the urine can't be voided, urine stagnates in the bladder, and infection sets in. Prostate infection may be similar or may be due to sexually transmitted bacteria. Chronic infection in the prostate, termed "chronic prostatitis" is characterized by pain or discomfort in the region of the prostate and may not even be true infection. This "chronic prostatitis" may actually be inflammation of the prostate without infection or the symptoms may or may not be prostatic in origin and the actual cause is unknown. Urologists call this "prostatodynia."

The normal amount of urine excreted by a man or a woman is variable depending on how much a person drinks, his or her state of hydration, along with many others factors such as diuretic medications, and activity. The rate of urine flow, on the other hand, and the amount of retained or residual urine remaining in the bladder after voiding is predictable. Generally, a flow rate in excess of 10cc/sec is considered normal although depending on the circumstances this can vary. The "normal" amount of retained urine will also vary somewhat depending on how full or stretched the bladder was before initiating a void but urologists generally like to see less than 1-2 ounces retained. A residual of 4 ounces (120cc) would usually be considered abnormal although this could be acceptable for some patients.

The pain and multitude of other symptoms you are experiencing may or may not be related to your prostate and/or your urinary tract. Only a physician examining you could provide more information to sort this out.

Hytrin is a medication that is approved by the Food and Drug Administration (FDA) to treat the symptoms of an enlarged prostate gland, termed benign prostatic hyperplasia (BPH). It relaxes the smooth muscles of the prostate and bladder outlet and allows for an improved flow of urine and lessens the other symptoms of BPH. The short-term side effects are that it can cause lowered blood pressure and dizziness and this is why a doctor must monitor the dose of drug when first starting Hytrin treatment. The long-term side effects are quite low. In fact, Hytrin is also used to treat high blood pressure which may require lifelong treatment

PSA AND PROSTATE BIOPSY

Q I had an ultrasound two months ago to see if I had prostate cancer. My PSA was up quite a bit. It was supposed to be uncomfortable, but it hurt like hell. I had seminal blood for two weeks. While inserted, my urologist took six biopsies from a gray scarred area along the bottom of my prostate - which turned out to be scar tissue, probably from a few long bouts with prostatitis. They hurt too. Six biopsies seem too much to me. Since then, I can't eat any spices or my anal sphincter or prostate itches and aches. Also, every time I have an orgasm my anal sphincter hurts as it contracts and squeezes. Is this going to last forever or wear off? Do you have any advice? Could the scar tissue be elevating my PSA?

A - The PSA or "prostate-specific antigen" blood test has become an extremely useful screening test for prostate cancer. An August 1996, research article in the New England Journal of Medicine by our CPDR group showed a very high accuracy of PSA for prostate cancer detection in both black and white men.* Since your PSA was elevated, you definitely needed the ultrasound and biopsy. Despite no evidence of prostate cancer, which is good, you may need a future biopsy if the PSA remains elevated. Ten to twenty percent of men will have prostate cancer diagnosed on subsequent biopsy even if the first one was negative. (It is possible that cancer was missed on the first biopsy). If you do need another biopsy, ask your urologist to prescribe pain and/or relaxant medicines prior to the procedure so you don't mind it so much.

Regarding your current complaints, they are unusual but are not serious and will resolve soon. Blood in the semen can last 4-8 weeks after a biopsy. This is not serious and it is OK to have sex during this time. Since the biopsy needle could have gone through the anal sphincter, it might be bruised and, therefore, this is why you have anal symptoms. These will also resolve. You might try warm baths and anti-inflammatory medicines such as Motrin. Scar tissue should not elevate PSA.

KEGEL EXERCISE FOR INCONTINENCE

Q I need some information about Kegel exercises for men. I have tried the exercises off and on and have quickly built up endurance doing the exercises. (i.e., I don't have trouble tightening the anal sphincter muscle for 10+ minutes or the muscles involved in stopping urination for 10+ minutes.) But, I quickly developed some slight discomfort/burning in my penile urethra. Not severe, but since I know little about the background and rationale of these exercises and can't find anyone locally who does, I thought I should stop and find out more. I have been able to inhibit ejaculation using these muscles but at the same time noticed a diminishing erection. My main concern:
is it possible that instead of increasing blood flow to the perineum, you may be causing some temporary blood shortage by tightening these muscles?

A - Kegel exercises were developed by Dr. Alfred Kegel in the 1940's and are pelvic muscle exercises to eliminate or improve urinary incontinence or leakage. They were an early form of biofeedback in that Dr. Kegel used a "pelvic meter" to measure the strength of muscle contraction and to teach the proper muscle groups to exercise.

In the last decade, Kegel exercise has been popularized and is an excellent technique for men and women to improve leakage problems. It is important, however, to have a professional teach one how to do the exercises properly. Many times patients may be exercising the wrong muscles for example, and may do more harm than good. Furthermore, "more is not necessarily better" in that too many exercises (too many reps) may actually fatigue the muscles and make matters worse. Men in particular, when told by their doctors to do Kegels many overexercise. The National Association for Continence (NAFC) organization in Union, SC (1-800- BLADDER) is an excellent resource in Kegel information and can provide a referral to a knowledgeable health care specialist.

Regarding the gentleman's question, he sounds like he is doing too many exercises and may be harming himself. He may be squeezing urine into the ducts of this prostate gland and setting up inflammation that may be causing the burning. Furthermore, as far as I know Kegels were never intended to prevent antegrade ejaculation or to increase penile blood flow. Regarding preventing ejaculation, there are better ways to treat premature ejaculation and, to my knowledge, Kegels have no scientific basis to improve penile blood flow.

TRANSURETHRAL RESECTION OF THE PROSTATE

Q Some time ago, I had trouble with my prostate so I couldn't urinate. This called for a "ream job." However, I didn't have insurance or Medicare so I had a catheter to drain my bladder for about 9 months until Medicare and Supplement kicked in. Before the operation, the urologist said that I would be able to have sexual intercourse like before. However, erections haven't been very plentiful. Before this operation, I had full erections every day. Could the catheter have something to do with this? I suspect that when my brain should have been giving the message for erection that the catheter stopped it from doing so. What could have caused this? I am taking blood pressure medication. The doctor says that this shouldn't have anything to do with stopping erections. Can you give me any advice?

A - The "ream job" you had was a "transurethral resection of the prostate" or TURP, an operation performed by a urologic surgeon to remove tissue from the prostate to allow free urination. The prostate gland sits like a donut surrounding the outlet of the bladder and as men get older the prostate gland enlarges and shrinks the "donut hole." If the prostate gets real big, it may block the bladder completely, as in your case. The urologist uses a telescope-like instrument, called a resectoscope, through the penis urethra to "enlarge the donut hole" and "unblock" the bladder. The resectoscope used electrical current and heat to cut the prostate tissue internally which is then sucked out through the resectoscope.

Erection problems, or impotence, after TURP happens in 5 to 10% of men. Since the nerves that help control erections hug the outside of the prostate, it is thought that the heat and electric current may injure these nerves in some men. Older men and men with other health problems such as diabetes, vascular disease, high blood pressure and smoking are at higher risk of these side effects. The catheter for a long time could have made the operation more difficult and may have increased the risk of impotence, too. Aside from all this, the old saying, "if you don't use it, you lose it" may also be playing a part - the 9 month period away from sex may have contributed physically and psychologically.

Advice now - see a urologist who specializes in erectile problems. There are a lot of options including vacuum erection devices, injection therapy, intraurethral suppository medication, and penile implants.

"TURP" AND INCONTINENCE

Q I have a problem that I hope you can help me with. I am 75 years old. While I was in the hospital for a heart attack, one of my doctors noticed that I was a little incontinent and he advised that I could have a procedure done that would improve this. I had very little leakage for approximately 10 years and my family doctor advised me to leave it alone. At the time I was using a women's "light" panty liner for protection. The leakage was very little and I only wore the pad so I wouldn't stain my pants. The problem did not get any worse, but I felt that since I was getting older I would like to eliminate this leakage and my family doctor referred me to a urologist. I was diagnosed with Benign prostatic hyperplasia (BPH) and I had a TURP in 1987. It turned out that I did not have BPH, but ever since that time my problems have been worse. Now I leak constantly and I have to use a male incontinence pad (pouch) which I have to change three times a day and more. During the night I get up three to four times to go to the bathroom and I fill a hospital-type urinal. I have a strong urine stream, both before and after the procedure. I do not have an enlarged prostate. And I have reduced my liquid intake as much as possible.

A - Urinary incontinence in men may occur after prostate surgery due to damage to the sphincter or "control valve" or may be due to bladder hyperactivity. Sometimes it is difficult to "sort-out" if the leakage is due to the sphincter, the bladder, or a combination of the two. Since you were having incontinence before the surgery, the doctor thought the leakage was due to the enlarged prostate. In this scenario, the enlarged prostate blocks the outflow path from the bladder, the bladder backs-up with urine over time, and the man experiences "overflow" incontinence. A TURP can help if this is the type of incontinence a man has. In your case, you may not have had overflow incontinence. Many times, special testing called "Urodynamics" can sort-out the type of incontinence a man has. I don't know if you had this testing but it could have shown the type of leakage you were experiencing. This urodynamic testing can also document if the prostate is really blocking the outflow and is useful for complex situations such as yours. If you did not have overflows incontinence and your prostate was not really blocking your flow, then the TURP could have done more harm than good. In your case, since you are leaking more, the TURP could have weakened the sphincter, the bladder could have gotten more hyperactive (related or unrelated to the TURP) or it could be a combination of these two factors.

Regardless of the past, you now need help. Men with incontinence should not suffer in silence. Excellent educational materials can be obtained from an organization called, "National Association for Continence" (1-800-BLADDER).* They can also direct you to a specialist in urinary incontinence. You now definitely need urodynamic testing to sort out your problem. There are a variety of treatments for male urinary incontinence including medications, pelvic muscle training exercises, biofeedback, electrical stimulation of the pelvic muscles, periurethral injection of collagen, the artificial urinary sphincter, and various external clamps and support devices.

THE PROSTATE AND SEXUAL FUNCTION

Q Over the years I have noticed that the urethral opening on the head of my penis has become larger, tearing down to the underside of the head. The crack has split down one half inch. What has caused this to happen and can anything be done about it?

A - This is an unusual problem. I surveyed my five staff urologic colleagues at Walter Reed Army Medical Center and they were all unaware of this problem. The most common cause of an enlarging urethral meatus is "iatrogenic," in other words, caused by physicians' interventions such as catherizations, cystoscopies, etc. The reverse problem, called "meatal stenosis," or scarring which decreases the urethral opening is actually much more common and can be caused by infection and trauma. One possibility for your problem could be subtle tearing of the frenulum penile skin during intercourse which could have torn into the meatus and enlarged it. I suggest you consult a urologist for an examination and consultation.

URETHRAL PROBLEMS

Q At age 44, I am alarmed that over the past year my orgasm has changed dramatically. What once was a pleasurable succession of intense and uncontrolled spasmodic throbs has been replaced with an almost relaxed numbed contraction. In just a year, what once was 5 or 6 strong pulsations is now sometimes only one mild little "jerk" accompanied by a tingly feeling in the head of my penis. What could this mean and why is it happening so suddenly? I'm fit, no medications and I don't drink.

A - The sudden change in orgasmic intensity and pleasure over a short period of time is enough to alarm anyone. An evaluation is necessary to evaluate for the onset of diabetes, a neurologic condition, or urologic disorders such as prostate enlargement or infection. You should have a medical evaluation! In the absence of medical disease, your condition could be due to a psychological disorder or stress, but medical disease must be ruled out first. Things that might suggest psychological problems are normal orgasm with masturbation or a different partner - i.e., situational or intermittent orgasmic dysfunction. That stress or fatigue is playing a role may be telling if orgasm is normal when well rested or away from the routine such as on a weekend get-away.

URINATION ADVICE

Q You have provided much good help and advice for us urinators of advanced years with our enlarged prostates, etc. One subject I haven't seen covered is advice for management of the process. The one big question I always have as the frequency increases concerns which is better: keeping it drained frequently or resisting as long as possible in order to maintain capacity and muscle control? I still have plenty of strength to hold it for hours past the first urge. Is this harmful?

A - Holding one's urine past the initial urges to void may be harmful and is not recommended. By doing this, the bladder can become spasmodic which, over time, can damage the muscular wall of the bladder. Over time, the bladder will thicken but not with quality muscle tissue but with scar tissue mixed within the muscle tissue. The bladder can also form "bladder diverticular" which are out pouchings of bladder lining between the thickened muscle fibers. These processes, over time, actually diminish the bladder's normal contractile ability during voiding. Sometimes, this process can progress such that the kidney's do not drain their urine properly into the bladder and kidney damage may result. It is much better to void regularly and at initial urges.

If you do have significant symptoms, which it sound's like you do, you should be medically evaluated. Your doctor, preferably a urologist, can provide a simple questionnaire, called an "AUA Symptom Score," which will gauge how much your symptoms are interfering with your life style. If you need treatment, gone are the days of surgery being the only option. Newer treatments include medications that shrink or relax the prostate and may be appropriate. Traditional surgery, called a transurethral resection of the prostate ("TURP") is still an excellent treatment for many men but even newer surgical techniques using lasers, stents, and microwave are commonly available. Just as you shouldn't hold your urine too long, don't hold off too long in seeing your doctor!

POST-VOID DRIBBLING

Q After I urinate, I frequently have from a few drops to a small stream that continues, which is annoying. I am 37 years old and in excellent health. Does this mean that there is a problem?

A - What you describe is the common problem of post-void dribbling (PVD), the loss of a small amount of urine after cessation of voluntary urination. This is annoying because of the wetness and staining of one's underwear, not to mention the embarrassing wetness that can appear on the trousers!

Usually, this problem is a result of not taking sufficient time to urinate and the proverbial "shaking the drips." In our hurried society, this last step is commonly omitted! Occasionally, PVD is due to a urinary tract abnormality such as a urethral stricture (scar tissue that narrows the urinary channel) or a prostate enlargement. Generally, these problems would also lead to a slow, narrow urine stream. If you have other symptoms along with the PVD, see your doctor or urologist.

PROSTATE CANCER HORMONAL THERAPY AND OSTEOPOROSIS

Q I am the physician staff leader of a large prostate cancer support group, and a patient recently asked about calcium supplements for men with prostate cancer who have had hormonal therapy to lower serum testosterone.

Since testosterone regulates calcium retention, are men treated for prostate cancer by testosterone-ablation therapy (orchiectomy, LHRH analogs, antiandrogens) more apt to develop osteoporosis, and, therefore, should they take calcium supplements? In the era of earlier hormonal therapy, many men are living many years after testosterone ablation, and this factor of osteoporosis may be relevant.

A - Men treated for prostate cancer by testosterone-ablation therapy do indeed have an increased incidence of osteoporosis. Although calcium intake of 1,000 to 1,500 mg/day is essential to help retard the progression of the osteoporosis, bone loss cannot be prevented with calcium supplements alone.

We recommend either nasal spray calcitonin (Miacalcin), 400 IU/day, or alendronate (Fosamax), 10 mg/day. Men who have had testosterone-ablative procedures should also have bone mineral density measurements of the vertebral and femoral neck to determine the extent of bone loss. This is routinely performed with a Dexa instrument. The response to therapy should also be followed annually by Dexa instrument measurements. Special thanks to Louis V. Avioli, MD, Washington University School of Medicine, St. Louis, Missouri, in helping CPDR answer this question.

USE OF ANTIANDROGEN IN PROSTATE CANCER

Q Is there an additional benefit to using an antiandrogen with an LH-RH agonist after 3 months?

A - The studies that have been performed testing the value of combined hormonal therapy (CHT) i.e. LH-RH agents plus an antiandrogen (flutamide, bicalutamide, and nilutamide) have all used continuous antiandrogens. We know that this regimen is beneficial (7-15 month survival advantage compared to LH-RH alone), however, the use of an antiandrogen for only the first 1-3 months of LH-RH therapy to treat the "flare" has not been proven in any clinical trial.

LAPAROSCOPIC PELVIC

Q What criteria should be used to perform a laparoscopic pelvic lymph node dissection? PSA? Gleason?

A - There are a number of good studies evaluating pre-treatment prognostic factors to determine the risk or odds of pelvic lymph node involvement with metastatic disease in men with clinically localized prostate cancer. The studies by Partin, et al. (updated study published in JAMA, 277:1445, 1997) using pretreatment PSA value, biopsy Gleason sum, and clinical T-stage category are the most widely accepted. These "nomograms" provide the risk for various prognostic factor groupings. It will be up to the clinician and patient to decide what level of risk they use to decide on PLND. Finally, the nomograms are general guidelines and we must educate patients not to focus on the exact risk percentage as gospel truth.

LYMPH NODE BIOPSY

Q Why are physicians not performing laparoscopic pelvic lymph node dissection?

A - Urologists, in general, are not performing LPLND because we now understand the use of prognostic factors to determine the risk or odds of lymph node positivity. Because of stage migration, the bulk of patients we are seeing in the late 1990's are at low risk of lymph node positivity and are appropriately not subjected to LPLND. Even at busy urology practices, there are not enough "high risk" patients (i.e. high PSA, high Gleason sum, high clinical stage) to keep the average, or even specialized urologist, proficient in LPLND. Furthermore, many surgeons have adopted the "mini-laparotomy" PLND using special retractors to gain exposure via a 4-6cm incision. The "mini-lap" PLND is quicker in most surgeon's hands and patients can still have outpatient procedures.

PERSISTENT ELEVATION OF PSA WITH NO CANCER

Q What do you do with the troublesome patient that experiences continuing elevation of PSA after 2 negative biopsies?

A - This type of patient is common to most urologist's practices and it worries the patient and doctor. We have found that percent-free-PSA is particularly useful in this setting.* We conducted a prospective study of 67 men, all of whom had at least two prior negative prostate biopsies and still had an elevated total PSA. All men had a free PSA test and a subsequent additional research biopsy consisting of TRUS-guided sextant plus two transition zone cores. Eleven of 67 men were diagnosed with cancer and a percent-free PSA <10% would have predicted 10 of the 11 cases.

PELVIC LYMPH NODE BIOPSY

Q Do you need to do a node dissection before radiation therapy for T3 disease in the face of a negative cross sectional imaging?

A -Clinical T3 prostate cancer has a 40-50% risk of pelvic lymph node metastases. Cross sectional imaging i.e. pelvic CT scans or MRI only detect size changes in nodes and are very inaccurate. Most current guidelines do not recommend cross sectional imaging staging studies for the majority of men with clinically localized disease unless they have high PSA, high Gleason and clinical T3 disease. For a man with unequivocal clinical T3 disease on DRE, I will obtain cross sectional imaging and if enlarged nodes are detected will request imaging-directed needle biopsy. Usually, the cross-sectional imaging is negative an I will recommend PLND prior to radiation in men who have unequivocal clinical T3 disease.

STAGE D1 PROSTATE CANCER

Q If a patient has node positive disease, should he be radiated locally for local control or treated with hormones?

A - Treatment of D1 disease remains controversial and the controversy centers around whether the clinician feels the patient has systemic disease and/or if local control in the face of systemic disease might prevent future additional metastases, prolong life, or provide palliative benefit. I favor long-term hormonal therapy and not proceeding with local radiation, although there are current clinical trials addressing this issue.

RADIATION VS SURGERY

Q Which patients would you steer away from radiation therapy in favor of radical prostatectomy?

A - The debate between radical prostatectomy (RP), and radiation (XRT) for clinically localized prostate cancer continues because contemporary randomized trials have not been performed. Without randomized trials, the best we can go on is nonrandomized case series. The best recent study, in my opinion, is the SEER (Surveillance, Epidemiology and End Results) review of 10 year treatment outcome for localized prostate cancer treated by RP, XRT or conservative treatment and stratified by grade. I use this study to counsel patients although I tell them that it is not randomized and that selection bias may have biased the results. My personal approach is to limit radical prostatectomy to clinical T1 and T2 disease in healthy men with a 10-15 year life expectancy. In general, this is men who are 70 years old or less. I tend to steer "young" men less than 60 to radical prostatectomy because of their long natural life-expectancy and my belief that RP offers the best "chance" for long-term disease control/cure, although individual men may or may not be cured by either treatment.

STAGING STUDIES AT THE TIME OF RECURRENCE

Q In the evaluation of rising PSA after surgery, radiation therapy for low volume disease, why do a bone scan or a CT scan when we don't do this therapy routinely beforehand?

A - I don't always do a bone scan and usually do not do a CT scan in the patient with PSA recurrence after prior radiation or radical prostatectomy. Our criteria for PSA recurrence after RP is >0.2ng/ml on two separate tests and some clinical trials use 0.4 or 0.5ng/ml as criteria for recurrence. In my experience, the chance of a positive bone scan in this setting of a low recurrent PSA is low. For example, in a clinical trial of proscar and flutamide for PSA-recurrence that I did with Dr. David Crawford, of 40 men who I enrolled who had PSA recurrence between 0.4-20.0ng/ml, none had a positive bone scan. In that trial CT scans were optional, and our practice was not to obtain them.

ADJUVANT RADIATION AFTER SURGERY

Q Radiation after radical prostatectomy: when do you do it, when do you not?

A - There are two ways to use radiation after radical prostatectomy: adjuvantly for pathologic stage T3/4 i.e. positive margins when the PSA is still undetectable or as salvage therapy used after there has been a PSA-recurrence. In the first setting, there is no randomized trial to tell us if radiation is better than observation for pT3/4 disease, although a SWOG/ECOG trial has been completed and results will be forthcoming over the next few years. My personal approach is not to routinely offer adjuvant XRT for pT3/4 disease; one-half of these patients don't fail. However, selected patients may be offered XRT if the surgeons had suspicion that gross disease was left behind.

Regarding salvage XRT, there was an excellent recent paper from Johns Hopkins that sheds light on efficacy.* In 82 men who had a PSA recurrence post-operatively, salvage XRT only "cured" 10%. In other words, in only 10% did the XRT result in a durable decrease in PSA during 5 years of follow-up. Interestingly, whether the PSA rose early (1st year) or later didn't seem to materially affect the very modest efficacy of salvage XRT. I am now using this new Hopkins paper to counsel men regarding the pros and cons of salvage XRT for rising PSA post-RT. With this new information, most men find that the "risk-benefit" analysis does not favor salvage XRT.

EARLY HORMONE REFRACTORY PROSTATE CANCER

Q What is the next step with someone with total androgen blockade, good functional status that is showing biochemical failure - rising PSA?

A - For a man who has been on total androgen blockade and now has a rising PSA, this is the first indication of hormone-refractory prostate cancer (HRPC). I use three successive rises in PSA to define a recurrence in this setting in the patient on regular follow-up, however, a single rise may be sufficient depending on the clinical setting. The first treatment in this setting is antiandrogen withdrawal which can be effective to lower the PSA in about one-half of men for several months to more than one year. When the PSA rises, it is also important to check the serum testosterone in those men on LH-RH agents. Occasionally, because of noncompliance the patient may have a noncastrate testosterone.

ERECTILE DYSFUNCTION FOLLOWING PROSTATE CANCER SURGERY AND VIAGRA®

Q I have a 64 year old patient who was operated on for prostate cancer two years ago. Prior to surgery, he had very adequate erections and he and his wife had a satisfactory sex life. However, since the surgery, his potency has not returned to the point of satisfactory intercourse. Might Viagra be effective in patients such as this man?

A - Before we talk about the most talked about drug of the year - and perhaps of the decade - Viagra® (sildenafil citrate), we need to discuss erectile dysfunction, or impotence, and prostate cancer surgery. Your 64 year old patient underwent a radical prostatectomy, the most common treatment for clinically localized adenocarcinoma of the prostate.1,2 Recent studies indicate that the 10 year cancer-specific survival for this operation is approximately 90 percent.3,4 Furthermore, despite the recent popularity of the brachytherapy (seed implant radiation), a very recent study found radical prostatectomy to provide superior recurrence-free survival rates than the implants for men with higher grade, clinical stage or prostate specific antigen (PSA) levels at the time of treatment.5 The potential disadvantage of radical prostatectomy is the possible side-effects of impotence and/or incontinence.
With regard to impotence, the nerves that innervate the corpus cavernosa, the natural hydraulic cylinders in the penis that fill with blood to produce an erection, travel on both sides of the prostate gland. Prior to the early 1980's, these nerves were invariably cut when a man underwent a radical prostatectomy and the operation rendered the man impotent. In the early 1980's, Dr. Patrick Walsh and his team from Johns Hopkins Hospital developed and perfected the nerve-sparing radical prostatectomy which preserves the nerves.6 For the carefully selected man with a small cancer and completely normal erections before surgery, the nerve-sparing radical prostatectomy can preserve his ability to get natural erections up to 80 percent of the time.7,8 However, since the average man who is diagnosed with prostate cancer is about 65 years old and may have some problems with erections going into the operation, the chance of a man getting erections back that are sufficient for intercourse may be much lower.9 Furthermore, many men have larger cancers and a bilateral nerve-sparing operation is not indicated. A unilateral nerve sparing operation can be performed but one recent study found that this operation was ineffective in allowing for the return of natural potency.10 Dr. Walsh, however, contends that unilateral and bilateral nerve sparing are effective in experienced surgeon's hands.11

Another key point that must be addressed is the definition of "satisfactory intercourse." Erectile function after nerve-sparing radical prostatectomy may range from complete impotence to partial erections that are insufficient for vaginal penetration to partial erections that are intermittently capable of penetration to normal potency. Potency rates in the medical literature vary depending on the above criteria for success. Even for the man who undergoes a successful nerve-sparing operation, it may take a full year or more before erections sufficient for intercourse return.

The key question men and their doctors want to know is if any additional or supplemental treatment will help restore or improve erections after non-nerve sparing or nerve sparing radical prostatectomy. As we approach the millennium, there are a plethora of treatments that can be tried. Vacuum erection devices (VED's) have been used successfully by men for more than a decade12 and may improve erections after radical prostatectomy. We are involved in a multicenter study to see if VED's can restore erection earlier after nerve-sparing operations. Intracavernosal injection therapy with vasoactive agents is also widely used and there are many physicians who will prescribe this treatment as soon as three months after surgery to speed recovery. Intraurethral suppository treatment with vasoactive prostaglandin (MUSE®) is also commonly prescribed.

Most recently, Viagra® (sildenafil citrate) has become FDA-approved as a type V oral phosphodiesterase inhibitor that will enhance the availability of cGMP and thereby promote vasodilation to facilitate erection.13 The FDA based its approval of Viagra® on 21 randomized, double-blind, placebo-controlled trials of over 3,000 men aged 19-87 years. The men had erectile dysfunction on average for five years and the efficacy was primarily based on the International Index of Erectile Dysfunction 15-item questionnaire. Seven of 10 Viagra® treated men reported improvement compared to 2 of 10 placebo-treated men.13 In Viagra's first three months on the market (from the 27 March 1998 approval date), 2.9 million prescriptions were dispensed.

Published experience in the setting of post-radical prostatectomy Viagra® treatment is limited. Discussions at recent medical meetings suggest that Viagra® is not likely to be beneficial if the man has had a non-nerve sparing radical prostatectomy. However, for the man who has had a unilateral nerve sparing or bilateral nerve sparing procedure and gets partial erections, Viagra® may facilitate firmer, fuller erections. Further research is needed to determine the efficacy of Viagra® and other options in the man who has undergone radical prostatectomy.

REFERENCES

Moul JW: Treatment options for prostate cancer: Part 1- Stage, Grade, PSA, and Changes in the 1990's. Am J Managed Care, 4(7):1031-1036, 1998.

Moul JW: Treatment options for prostate cancer: Part 2- Early and Late Stage and Hormone Refractory Disease. Am J Managed Care, 4(8):1171-1180, 1998.

Lu-Yao GL, Yao SL: Population based study of long term survival in patients with clinically localized prostate cancer. Lancet, 349:906-910, 1997.

Gerber GS, Thisted RA, Scardino PT, et. al.: Results of radical prostatectomy in men with clinically localized prostate cancer. JAMA, 276:615-619, 1996.

D'Amico AV, Whittington R, Malkowicz SB, et. al.: Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA, 280:969-974, 1998.

Walsh PC, Donker PJ: Impotence following radical prostatectomy: insight into etiology and prevention. J Urol, 128:492-497, 1982.

Walsh PC, Epstein JI, Lowe FC: Potency following radical prostatectomy with wide unilateral excision of the neurovascular bundle. J Urol, 138:823, 1987.

Catalona WJ, Bigg SW: Nerve sparing radical prostatectomy: evaluation of results after 250 patients. J Urol, 143:538, 1990.

Fowler FJ, Barry MJ, Lu-Yao G, Roman A, Wasson J, Wennberg JE: Patient reported complications and follow-up treatment after radical prostatectomy. Urology, 42:622-629, 1993.

Talcott JA, Rieker P, Propert KJ, Clark JA, Wishnow KI, Loughlen KR, Richie JP, Kantoff PW: Patient reported impotence and incontinence after nerve-sparing radical prostatectomy. J Nat Cancer Inst, 89:1117-23, 1997.

Walsh PC: Urology survey: Patient reported impotence and incontinence after nerve-sparing radical prostatectomy. J Urol, 159(1):308-309, 1998.

Moul JW, McLeod: Negative pressure devices in the explanted penile prosthesis population. J Urol, 142:729, 1989.

Lamberg L: New drug for erectile dysfunction boon for many, "Viagravation" for some. JAMA, 280:867-869 1998.

INTERMITTENT HORMONAL THERAPY

Q I have been undergoing hormonal therapy for 18 months following a radical prostatectomy. All of a sudden, I am hearing about a therapy called intermittent hormonal therapy (IHT) which has never been mentioned as an option for me. How effective is this therapy, and how do I determine if I am a candidate for it?

A - Intermittent hormonal therapy (IHT) is an approach popularized in Canada in which all hormonal therapy is measurements. Specifically, a typical patent would start with 9 months of complete hormonal therapy with a LH-RH injection (Lupron or Zolodex) and antiandrogen pills (flutamide, bicalutamide, or nilutamide). After this time on medications if the PSA Level falls to a real low level (typically less than <0.1 Ng/ml), the injections and pills are stopped completely. The doctor and patient then monitor the PSA and testosterone with monthly blood tests and the man would restart 9 more months of medication when the PSA Rose to a predetermined level (typically 4-10 Ng/ml range depending on the individual patient).
Early small studies with IHT are encouraging, however, large studies with long follow-up are not yet available so most doctors still consider IHT to be "investigational". I feel IHT is a reasonable treatment for many men with prostate cancer and I will offer it but I make sure the men are well informed that if is still investigatinal and not yet standard-of-care.

NEOADJUVANT HORMONAL THERAPY

Q If experience shows that a large percentage of prostate tumors are subsequently found to be understaged, way isnít neoadjuvant hormonal therapy routinely used in conjunction with radical prostatectomies?

A - INeoadjuvant hormonal therapy (NHT) is the treatment of using LH-RH injection and antiandrogen pills for a period of months prior to radical prostatectomy (RP) to improve outcome. Early studies used NHT for 3 months and the results showed that the treatment shrank the tumor size but the cancer recurrence rates between men who did or didnít get NHT was the same. Therefore, most urology surgeons list enthusiasm for NHT. More recently, study in Canada suggests that using NHT for 8 months prior to RP has improved outcome. The problem with 8 months is a pragmatic one for many doctors and patients: they are committed to the operation and do not want to put it off for that lone. If the Canadian studies pan-out, then 8 month NHT may become more popular. Alternatively, it may be just as beneficial to use the hormones only after RP in selected men and this is called "adjuvant hormonal therapy "(AHT) ñ These studies are also getting started.

DECREASE IN PENILE LENGTH

Q After recovering from my radical prostatectomy, I noted an obvious decrease in penile length. In selecting surgery over radiation, I had considered the possible side effects of impotence and incontinence, but not this other outcome. The surgeon says that he "pulled down" on the bladder neck to reconnect it with the urethra after excising the prostate, but it seems to me that the reconnection technique would also likely have a "pulling up" effect on the he urethra with an attendant effect on the external penis. How common is the situation I have described?

A - Shortening of the penis is more common than many surgeons admit to after radical prostatectomy (RP). I have had many patients tell me that their penis is shorter after RP. The reasons are not fully understood but I can think of two possibilities. First, the lower part of the incision for RP is close to the base of the penis and natural scar tissue with healing may "trap" more of the penis below the skin. Second, the re-hook-up of the urethra tube to the bladder may shorten the urethra and not allow the erect penis to be as long. Other possibilities are that the nerve supply to the penis is affected and general "tone"" of the penis is more flacid because it is not storing as much blood as before the operation. Despite this side effect, the benefit of RP as a curative treatment for early stage prostate cancer is becoming clear. The Johns Hopkins Hospital recently reported (JAMA, 281; 1591, 1999) results of almost 2000 men who had RP between 1982 and 1997. There was an 82% chance of 15-year survival free of metastases (spread).
Furthermore, as men are getting screened more, we are picking up early stage cancer that is easier to treat and the odds of side effects such as impotence; incontinence and penile shortening are less.

VIAGRA THERAPY

Q I have a 64-year-old patient who was operated on for prostate cancer 2 years ago. Prior to the surgery, he had adequate erections and he and his wife has a satisfactory sex life. However, since the surgery, his potency has not returned to the point of satisfactory intercourse. Might sildenafil (Viagra) be effective in treating this man’s impotence?

A- Before we talk about sildenafil – the most talked about drug of 1998 (and perhaps of the decade) – we need to discuss erectile dysfunction, or impotence, and prostate cancer surgery.

This 64-year-old patient underwent a radical prostatectomy, the most common treatment for clinically localized adenocarcinoma of the prostate. [1,2] Recent studies indicate that the 10-year cancer-specific survival for patients after this operation is approximately 90%. [3,4] Despite the current popularity of brachytherapy (seed-implant radiation), a recent study found radical prostatectomy to provide superior recurrence-free survival rates than the implants for men with higher grade, clinical stage, or prostate-specific antigen (PSA) levels at the time of treatment. [5] The potential disadvantage of radical prostatectomy is the possibility of side effects such as impotence and/or incontinence.

With regard to impotence, the nerves that innervate the corpus cavernosa-the natural hydraulic cylinders in the penis that fills with blood to produce an erection- travel on both sides of the prostate gland. Prior to the early 1980s, these nerves were invariably cut when a man underwent a radical prostatectomy, and the operation rendered the man impotent.

Nerve-Sparing Prostatectomy
In the early 1980s, Dr Patrick Walsh and his team from Johns Hopkins Hospital developed and perfected the nerve-sparing radical prostatectomy, which preserves the nerves. [6] For the carefully selected man with a small cancer and completely normal erections before surgery, the nerve-sparing radical prostatectomy can preserve his ability to get natural erections up to 80% of the time. [7,8]

However, since the average man who is diagnosed with prostate cancer is about 65 years old and may have some problems with erections before the operation, the chance of a man getting erections back that are sufficient for intercourse actually may be much lower. [9] Furthermore, many men have larger cancers, and a bilateral nerve-sparing operation is not indicated in these patients.

A unilateral nerve-sparing operation can be performed, but one recent study found that this procedure was ineffective in allowing for the return of natural potency. [10] Dr. Walsh, however, contends that both unilateral and bilateral nerve-sparing operations are effective in an experienced surgeon’s hands. [11]

Another Key point that must be addressed is the definition of "satisfactory intercourse". Erectile function after nerve-sparing radical prostatectomy may range from complete impotence to partial erections that are insufficient for vaginal penetration to partial erections that are intermittently capable of penetration to normal potency. Potency rates in the medical literature vary depending on the above criteria for success. Even for the man who undergoes a successful nerve-sparing operation, it may take a full year or more before erections sufficient for intercourse return.

Plethora of Treatments
The key question for men and their doctors is whether any supplemental treatment will help restore or improve erections after non-nerve-sparing or nerve-sparing radical prostatectomy. As we approach the millennium, there are a plethora of treatments that can be tried.

Vacuum erection devices (VEDs) have been used successfully by men for more than a decade [12] and may improve erections after radical prostatectomy. We are involved in a multicenter study to see if VEDs can restore erection earlier after nerve-sparing operations.

Intracavernosal injection therapy with vasoactive agents is also widely used and there are many physicians who will prescribe this treatment as soon as 3 months after surgery to speed recovery. Intraurethral suppository treatment with vasoactive prostaglandin (MUSE) is also commonly prescribed.

Approval of Sildenafil
In March 1998, the FDA approved sildenafil as a type V oral phosphodiesterase inhibitor that enhances the availability of cGMP and thereby promotes vasodilation to facilitate erection. [13] In sildenafil’s first 3 months on the market, 2.9 million prescriptions were dispensed.

The FDA based its approval of sildenafil on 21 randomized, double-blind, placebo-controlled trials of more than 3,00 men aged 19 to 87 years. The men in these studies had erectile dysfunction on average for 5 years, and the efficacy was primarily based on the International Index of Erectile Dysfunction 15-item questionnaire. Seven of 10 sildenafil-treated men reported improvement, compared to 2 of 10 placebo-treated men. [13] Published experience in the setting of post-radical prostatectomy sildenafil treatments is limited. Zippe, et al. Recently reported on 28 men finding an 80% response in those who has underwent a bilateral nerve-sparing operation but no responders in the 3 men who had a unilateral nerve-sparing or the 10 subjects who had non-nerve-sparing operations. [14]

Further research is needed to determine the efficacy of sildenafil and other options in the man who has undergone radial prostatectomy.

References

Moul JW: Treatment options for prostate cancer: Part 1. Stage, grade, PSA, and changes in the 1990s. Am J Managed Care 4(7):1036-1036, 1998.

Moul JW: Treatment options for prostate cancer: Part 2. Early and late stage and hormone refractory disease. Am J Managed Care 4(8):1171-1180, 1998.

Lu-Yao GL, Yao SL: Population based study of long term survival in patients with clinically localized prostate cancer. Lancet 349:906-910, 1997.

Gerber GS, Thisted RA, Scardino PT, et al: Results of radical prostatectomy in men with clinically localized prostate cancer. JAMA 276:615-619, 1996.

D’Amico AV, Whittington R, Malkowicz SB, et al: Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA 280:969-974, 1998.

Walsh PC, Donker PJ: Impotence following radical prostatectomy: Insight into etiology and prevention. J Urol 128:492-497, 1982.

Walsh PC, Epstein JI, Lowe FC: potency following radical prostatectomy with wide unilateral excision of the neurovascular bundle. J Urol 138:823, 1987.

>
Catalona WJ, Bigg SW: nerve sparing radical prostatectomy: evaluation of results after 250 patients. J Urol 143:538, 1990.

Fowler FJ, Barry MJ, Lu-Yao G, et al: patient reported complications and follow-up treatment after radical prostatectomy. Urology 42:622-629, 1998.

Talcott JA, Rieker P, Propert KJ, et al: patient reported impotence and incontinence after nerve-sparing radical prostatectomy. J Natl Cancer Inst 89:1117-23, 1997.

Walsh PC: Urology survey: Patient reported impotence and incontinence after nerve sparing radical prostatectomy. J Urol 159(1):308-309, 1998.

Moul JW, McLeod: Negative pressure devices in the explanted penile prosthesis population. J Urol 142:729, 1989.

Lamberg L: New drug for erectile dysfunction boon for man, "Viagravation" for some. JAMA 280:867-869, 1998.

Zippe CD, Kedia AW, Kedia K, Nelson DR, Agarwal A: Treatment of erectile dysfunction after radical prostatectomy with sildenafil citrate (Viagra). Urology 52:963-966, 1998.
Back to Directory

Q When I read about treatment options for prostate cancer, radical prostatectomy, external beam radiation, brachytherapy, and sometimes cryotherapy are listed as the primary therapies. But what about proton therapy? Why is it seldom mentioned? How does it differ from the other radiation treatments, and how does it compare to the other therapies in terms of effectiveness and morbidity?

A - Proton beam therapy is a type of radiation that delivers a dose of proton energy to cancerous tissues using a synchrotron. (1) The rationale for its use in prostate cancer is that it can deliver a larger dose of radiation to the prostate gland and tumor with a much lower dose to the surrounding normal tissues. In theory, this should allow better cancer treatment with fewer side effects and complications from the radiation to adjacent normal structures, especially the intestine and rectum. In the United States, proton beam therapy has been delivered at physics laboratory type accelerators since as early as 1955, at Berkeley, CA and Boston, MA. (1) In 1990, the first completely medically-oriented proton beam facility opened in Loma Linda University, California and this remains the only facility in the US.

Regarding clinical data, the proton facility at Massachusetts General Hospital/Harvard Cyclotron Laboratory has treated 191 patients with T3 and T4 (stage C) prostate cancer as of 1993. (2) They performed a phase III clinical research trial comparing traditional radiation therapy to proton boost to the prostate plus traditional radiation to the pelvis. As of 1991, the results of both treatments were similar with 81% versus 89% local control rate at 5 years. Regarding safety, the traditional radiation fared better regarding post-irradiation rectal bleeding. Thirty-four percent of the proton treated patients had rectal bleeding versus 16% of the traditionally treated patients (P=0.013). (2) This group has recently reported an update of their experience with proton beam boost radiation for locally advanced stage T3-T4 prostate cancer. (3) Their randomized trial of 103 patients who received the proton beam boost compared to 99 who received conventional radiation therapy showed no significant differences in overall survival, disease-specific survival, total recurrence-free survival, or local control between the two treatments. The average follow-up for the study is 61 months. Only for the subgroups of men with poorly differentiated tumors was the proton boost superior regarding local control. Rectal bleeding and urethral stricture complications were higher in the proton boost group.

As noted above, the Loma Linda University proton therapy facility is the first and only completely medically-oriented unit in the United States. The group started treating prostate cancer in December 1991 and in 1997 reported their initial experience. (4) This first report was on 106 men with stages T2b(B2), T2b(B2), and T3(C) prostate cancer, followed a mean of 20.2 months (longest follow-up of 30 months). These patients received 4500 cGy of standard pelvic photon radiotherapy and a proton boost of 3000 cGy equivalent to the prostate for a total dose of 7500 cGy equivalent. Only 12% of men experienced rectal or urinary symptoms (grade 1 or 2) so the early results are encouraging regarding safety. However, with short follow-up it is impossible to draw conclusions regarding efficacy. Furthermore, the authors only reported "PSA normalization" i.e. £4.0 ng/ml as their efficacy endpoint, which is inadequate to evaluate even early outcome data. If the Loma Linda proton treatment functions similarly to the Harvard research unit treatment, we may expect that future data will show that it is at least as effective as traditional photon radiation at the 5 year follow-up. However, the Harvard studies noted above show that proton beam radiation had a higher rate of rectal bleeding at the 5-year follow-up, therefore, the safety of proton therapy compared to photon is still in question.

In 1998, the Loma Linda University group reported updated results of proton beam radiotherapy for prostate cancer. (5) Slater, et. al., reported on 643 men representing their consecutive experience between December 1991 and December 1995. The overall clinical disease-free survival (DFS) was 89% at 5 years. Using PSA as an endpoint of disease control (3 rises), the 4.5 year DFS rate was 100%, 89%, 72%, and 53% for patients with starting PSA <4.0, 4.1-10.0, 10.1-20.0, and >20.0, respectively. Minimal radiation proctitis was seen in 21% of patients and toxicity of greater severity was seen in less than 1%. The authors used protons only for men with low risk of lymph node involvement (N=319). The authors do not specify how the risk-assessment for pelvic lymph node disease was determined.

Because proton beam radiation alone or proton beams plus a traditional photon radiation dose to the pelvis is only performed at one site, it is considered as a “non-standard” treatment for prostate cancer. It probably is at least as effective as traditional photon conformal radiation, but has not yet been compared to standard radiation in a randomized trial. >Because it is apparently quite a bit more expensive than traditional radiation, some insurance companies and HMO's will not pay for it because it has not been proven superior to regular radiation.

REFERENCES
Suit H, Vrie M: Proton beams in radiation therapy. J. Natl. Cancer. Inst., 84:165-168, 1992.

Benk VA, Adams JA, Shipley WU, et. al.,: Late rectal bleeding following combined X-ray and proton high dose irradiation for patients with stages T3-T4 prostate carcinoma. Int. J. Radiat. Oncol.- Biol. Phys, 25:551-557, 1993.

Shipley WU, Verhey LJ, Munzenrider JE, et. al.,: Advanced prostate cancer: The results of a randomized comparative trial of high dose irradiation using photons alone. Int. J. Radiat. Oncol.- Biol. Phys, 32:3-12, 1995.

Yonemoto LT, Slater JD, Rossi CJ, et. al.,: Combined proton and photon conformal radiation therapy for locally advanced carcinoma of the prostate: preliminary results of a phase I/II study. Int. J. Radiat. Oncol.- Biol. Phys., 37:21-27, 1997.

Slater JD, Yonernoto LT, Rossi CJ et. al.,: Conformal proton therapy for prostate cancer. Int. J. Radiat. Oncol.-Biol. Phys, 42:299-304, 1998.

Q: I had a radical prostatectomy in 1986 at the age of 51. When my PSA started to rise again to 0.7 ng/ml, I underwent external beam radiation in 1992, which dropped my PSA to zero. But by June 1999 my PSA rose again to 0.7 ng/ml. I had a biopsy that one pathologist read as benign prostatic tissue, another read it as adenocarcinoma. My bone scan and CAT scan were negative. Now my PSA is 0.8 ng/ml. I was advised that the cancerous tumor found by the second pathologist could be cured by a salvage cystectomy (removal of the bladder) which I understand is an "experimental technique". Given these facts, my question is "when should I start on hormones or consider an orchiectomy?" morbidity?

A - Great question on the continuing debate about the most appropriate treatment for "PSA-Only Recurrence" after prior local treatments. Here are a few comments about a number of issues raised by this question:

Radical prostatectomy must be considered the standard of care for a 51- year old man. I feel this was a most appropriate treatment in this case and for most men in this young age group who are otherwise healthy. Unfortunately, it does not cure everyone and the cure rates go down as the stage, Gleason grade and PSA go up. We are not told what these values were in this case, but my guess is that you had non-organ confined (pathologic stage T3) prostate cancer or a Gleason sum of greater than or equal to 7 or a PSA greater than 10 ng/ml at the time of diagnoses/initial treatment. All these factors are associated with higher rates of recurrence.

The radiation therapy given to the prostate area when the PSA rose to 0.7 ng/ml is called "salvage radiation". Its value to treat PSA recurrence is controversial. Studies from John Hopkins and from CPDR, found that it benefits 10-25% of men. In other words, 5 years after the radiation, only 10-25% of men had their PSA remaining undetectable or very low. The majority of men had rising PSA suggesting that the radiation did not provide a durable benefit. On the other hand, studies from Wayne State University, in Detroit and Jefferson Medical College are more optimistic and suggest that 40-60% of men have a durable response of 5-years or more. Recent guidelines tell doctors to start salvage radiation before the PSA reaches 1.5 ng/ml and to use at least 6400 cGy (the dose) of radiation.

The proposed treatment now of "salvage cystectomy" for a rising PSA and positive biopsy after prior radical prostatectomy and salvage radiation is considered experimental. In fact, I have never heard of anyone undergoing "salvage cystectomy" in this setting. Unfortunately, the latest PSA recurrence is highly likely to represent occult systemic prostate cancer cells i.e. microscopic distant metastases and additional local treatment of any type is likely to be futile.

Having been pessimistic about further local treatment, I am very optimistic about systemic treatment, in this case, some form of hormonal therapy. My personal opinion based on recent study is that early hormonal therapy before the development of clinical metastases on bone scans or CT scans in better than waiting for metastases i.e. traditional stage D2 disease. This opinion is based primarily on the study by Messing, et. al., in the December 1999 NEJM showing a strong survival benefit to early hormonal therapy for stage D1 (lymph node metastases) after radical prostatectomy. If you were a patient at Walter Reed, We would likely order a Prostascint® scan. If this test was negative for metastases, I would offer traditional hormonal therapy (i.e. orchiectomy or LH-RH agonist injections) or non-traditional hormones (i.e. antiandrogen alone or with finasteride or intermittent hormonal therapy) If the bone scan or Prostascint® scan showed metastases, I would strongly recommend traditional hormonal therapy at this time.

KEGEL EXERCISE FOR INCONTINENCE

TRANSURETHRAL RESECTION OF THE PROSTATE

Q: Some time ago, I had trouble with my prostate so I couldn't urinate. This called for a "ream job." However, I didn't have insurance or Medicare so I had a catheter to drain my bladder for about 9 months until Medicare and Supplement kicked in. Before the operation, the urologist said that I would be able to have sexual intercourse like before. However, erections haven't been very plentiful. Before this operation, I had full erections every day. Could the catheter have something to do with this? I suspect that when my brain should have been giving the message for erection that the catheter stopped it from doing so. What could have caused this? I am taking blood pressure medication. The doctor says that this shouldn't have anything to do with stopping erections. Can you give me any advice?

TURP" AND INCONTINENCE

POST-VOID DRIBBLING

Q After I urinate, I frequently have from a few drops to a small stream that continues, which is annoying. I am 37 years old and in excellent health. Does this mean that there is a problem?

PROSTATE CANCER HORMONAL THERAPY AND OSTEOPOROSIS

Q: I am the physician staff leader of a large prostate cancer support group, and a patient recently asked about calcium supplements for men with prostate cancer who have had hormonal therapy to lower serum testosterone.

USE OF ANTIANDROGEN IN PROSTATE CANCER

Q: Is there an additional benefit to using an antiandrogen with an LH-RH agonist after 3 months?

PERSISTENT ELEVATION OF PSA WITH NO CANCER

Q: What do you do with the troublesome patient that experiences continuing elevation of PSA after 2 negative biopsies?

RADIATION VS SURGERY

Q:Which patients would you steer away from radiation therapy in favor of radical prostatectomy?

STAGING STUDIES AT THE TIME OF RECURRENCE

Q: In the evaluation of rising PSA after surgery, radiation therapy for low volume disease, why do a bone scan or a CT scan when we don't do this therapy routinely beforehand?

ADJUVANT RADIATION AFTER SURGERY

Q: Radiation after radical prostatectomy: when do you do it, when do you not?

EARLY HORMONE REFRACTORY PROSTATE CANCER

Q: What is the next step with someone with total androgen blockade, good functional status that is showing biochemical failure - rising PSA?

ERECTILE DYSFUNCTION FOLLOWING PROSTATE CANCER SURGERY AND VIAGRA®

INTERMITTENT HORMONAL THERAPY

Q: I have been undergoing hormonal therapy for 18 months following a radical prostatectomy. All of a sudden, I am hearing about a therapy called intermittent hormonal therapy (IHT) which has never been mentioned as an option for me. How effective is this therapy, and how do I determine if I am a candidate for it?

NEOADJUVANT HORMONAL THERAPY

Q: If experience shows that a large percentage of prostate tumors are subsequently found to be understaged, way isnít neoadjuvant hormonal therapy routinely used in conjunction with radical prostatectomies?

DECREASE IN PENILE LENGTH

Q: After recovering from my radical prostatectomy, I noted an obvious decrease in penile length. In selecting surgery over radiation, I had considered the possible side effects of impotence and incontinence, but not this other outcome. The surgeon says that he "pulled down" on the bladder neck to reconnect it with the urethra after excising the prostate, but it seems to me that the reconnection technique would also likely have a "pulling up" effect on the he urethra with an attendant effect on the external penis. How common is the situation I have described?